Journal Article > Study

Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.

Journal Article > Commentary

High-risk industries such as aviation and nuclear power routinely employ rehearsal as a learning technique. Health care has been working to utilize simulation learning in daily work. This commentary reviews elements of a successful simulation program to enable practice of rare or complex procedures as a way to safely build team and individual skills.